Atrial Tachycardias After Atrial Fibrillation Ablation

HomeCirculation: Arrhythmia and ElectrophysiologyVol. 11, No. 6Atrial Tachycardias After Atrial Fibrillation Ablation Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBAtrial Tachycardias After Atrial Fibrillation AblationWhat Matters for Identification of the Region of Interest? Yang Liu, MD, Michael Shehata, MD and Xunzhang Wang, MD Yang LiuYang Liu Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA (Y.L., M.S., X.W.). Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China (Y.L.). , Michael ShehataMichael Shehata Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA (Y.L., M.S., X.W.). and Xunzhang WangXunzhang Wang Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA (Y.L., M.S., X.W.). Originally published1 Jun 2018https://doi.org/10.1161/CIRCEP.118.006480Circulation: Arrhythmia and Electrophysiology. 2018;11:e006480See Article by Casado Arroyo and Laţcu et alElectrical isolation of pulmonary veins (PVs) is the cornerstone of catheter ablation for atrial fibrillation in clinical practice but may potentially predispose to iatrogenic left atrial tachycardias (ATs) particularly in combination with additional left atrial ablation. The reported incidence of ATs after atrial fibrillation ablation varies from 2.9% to 40% highly dependent on index ablation strategies.1–4 Compared with PV isolation alone, an aggressive strategy can be associated with a higher risk of developing ATs during follow-up.5,6 In the setting of PV isolation alone, recurrent ATs typically have a focal origin in nature from reconnected PVs and may account for up to 80% of AT incidence, irrespective of segmental or circumferential ostial PV ablation.1,7 After extensive left atrial ablation, the majority of ATs are macroreentrant, and the reentrant circuits most commonly traverse incomplete or recovered linear lesions (such as left atrial roof or mitral isthmus lines) or rotate around other anatomic obstacles.3,8,9 These ATs, especially the latter, are frequently incessant and poorly tolerated because of relatively rapid ventricular response. Symptoms experienced may be even worse than those from atrial fibrillation before the index ablation. Thus, there is often a therapeutic imperative for ablation of ATs in such scenarios because management of these tachycardias is difficult using a pharmacological approach. However, detailed mapping of these arrhythmias based in part on activation time is well known to be challenging and sometimes confusing because of previous ablation with resultant complex atrial substrate. Entrainment maneuvers may be helpful for rapid localization of AT origin, but repeat attempts can often result in tachycardia termination or degeneration into atrial fibrillation. It is, therefore, important for operators to have a preliminary idea regarding possible mechanism or source of postablation ATs to guide a mapping strategy and avoid indiscriminate entrainment pacing. In the current issue of Circulation: Arrhythmia and Electrophysiology, Casado Arroyo et al10 report the use of qualitative and quantitative analysis of the surface ECG and coronary sinus (CS) activation characteristics during tachycardia to facilitate distinction of left atrial roof-dependent atrial flutter (AFL) and mitral annular (MA) AFL after catheter ablation of atrial fibrillation. This study presents potential underlying practical principles that may aid operators in the electrocardiographic and electrophysiological assessment of complex ATs and rapid identification of the region of interest before entrainment attempts or mapping.In their study, the authors determined the P-wave morphology by reviewing the recordings for an area without superimposed T waves and defined the polarity by analysis of P waves during the 80 ms before the tallest peak positive or negative deflection in lead V1. On the contrary, CS activation patterns and time difference between the earliest and latest atrial signals were assessed according to CS recordings acquired by a decapolar diagnostic catheter positioned in the proximal CS. As a result, 2 different roof-dependent circuits, including a posteroanterior direction with the activation wavefront being ascendant on the posterior wall and descendant on the anterior wall and an anteroposterior direction, were identified in their study, and surface ECG characteristics in association with these 2 types of circuits were elucidated in detail, similar to that observed in counterclockwise and clockwise MA flutters, respectively. Additionally, they found that roof-dependent AFL frequently demonstrates a more simultaneous CS activation pattern with activation time difference ≤39 ms, whereas MA flutter usually has a sequential CS activation either proximal to distal or distal to proximal with activation time difference >39 ms. Using this algorithm based primarily on the CS activation, roof-dependent AFL was diagnosed with 100% sensitivity and 97% specificity.In general, identifying the tachycardia origin and potential mechanism by analyzing routine electrocardiographic leads should be the first step for the invasive electrophysiologist. Unlike focal ATs with clear isoelectric intervals on the surface ECG, macroreentrant ATs, except those with a critical isthmus involving a relatively small amount of atrial myocardium, usually lack an obvious isoelectric period, and therefore may be difficult to find a discrete starting point and determine P-wave electrocardiographic characteristics. In the present study, Casado Arroyo et al10 used the peak deflection in lead V1 as a reference to characterize the P-wave morphology of roof-dependent and MA flutters. An important contribution of this report is to elucidate the detailed surface ECG features of roof-dependent AFL with both activation directions. Although these electrocardiographic characteristics fail to provide a unique opportunity to distinguish between roof-dependent and MA flutters, they allow for further comparative studies with other macroreentrant ATs. It is noteworthy that the P-wave morphology may be less accurate in patients with severe atrial fibrosis or after extensive catheter or surgical atrial ablation, leading to nonuniform atrial wavefront propagation with resultant deviated atrial activation vectors or low-amplitude P waves. Furthermore, the predictive valve of P-wave morphology for precise anatomic localization of macroreentrant circuits is usually limited because P waves produced by different underlying substrates may appear similar if a similar septal and left atrial activation exists.11It is well understood that, as a standard component of the electrophysiological study, the close analysis of CS recordings to disclose MA activation patterns provides a critical clue to rapidly identify the most likely mechanism of left atrial ATs after atrial fibrillation ablation. In roof-dependent AFL, the activation wavefront propagates from the roof to the anterior or posterior wall of the left atrium so that a nonsequential or simultaneous activation pattern is recorded along the CS catheter. However, the pattern of CS activation for prediction of roof-dependent AFL may be nonuniform particularly in patients with prior extensive left atrial ablation. In a previous study by Pascale et al12 on 140 consecutive patients with sustained AT after stepwise ablation of persistent atrial fibrillation, the authors found that the CS activation patterns in roof-dependent AFL were from proximal to distal in 43% of ATs, chevron/reverse chevron (namely simultaneous or nonsequential) in 30%, and from distal to proximal in 27%. The most likely cause of sequential CS activation in roof-dependent AFL is local atrial conduction delay or block attributable to additional linear lesions. Furthermore, the disparate activation between the left atrium and CS may occur if previous ablation targeted the endocardial and epicardial aspects of the CS and led to partial left atrium–CS disconnection,13 which would further increase the complexity of CS activation patterns during roof-dependent AFL. Additionally, the majority of left atrial centrifugal ATs originating from the posterior or anterior wall also demonstrate a nonsequential CS activation pattern. Rarely, the earliest CS activations on both the proximal and the distal bipoles during clockwise tricuspid annulus AFL can be recorded when left atrium is activated predominantly over the Bachmann bundle.14In summary, Casado Arroyo et al10 have well characterized the typical surface ECG features observed in roof-dependent AFL and propose a valuable diagnostic algorithm combining qualitative and quantitative analysis of the CS activation sequence to facilitate the identification of roof-dependent AFL in distinction from MA flutter. Some pitfalls in the analysis of the CS activation for guiding subsequent mapping and entrainment maneuvers should also be taken into careful consideration.DisclosuresDr Liu receives research grants from the National Natural Science Foundation of China (NSFC-81400259) and the Natural Science Foundation of Guangdong Province (2014A030310470) and an educational fee from Boston Scientific. The other authors report no conflicts.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.http://circep.ahajournals.orgXunzhang Wang, MD, Heart Institute, Cedars Sinai Medical Center, Los Angeles 90048, CA. E-mail [email protected]References1. Gerstenfeld EP, Callans DJ, Dixit S, Russo AM, Nayak H, Lin D, Pulliam W, Siddique S, Marchlinski FE. Mechanisms of organized left atrial tachycardias occurring after pulmonary vein isolation.Circulation. 2004; 110:1351–1357. doi: 10.1161/01.CIR.0000141369.50476.D3.LinkGoogle Scholar2. Wasmer K, Mönnig G, Bittner A, Dechering D, Zellerhoff S, Milberg P, Köbe J, Eckardt L. Incidence, characteristics, and outcome of left atrial tachycardias after circumferential antral ablation of atrial fibrillation.Heart Rhythm. 2012; 9:1660–1666. doi: 10.1016/j.hrthm.2012.06.007.CrossrefMedlineGoogle Scholar3. 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Different patterns of interatrial conduction in clockwise and counterclockwise atrial flutter.Circulation. 2001; 104:1153–1157.LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited ByFochler F, Yamaguchi T, Kheirkahan M, Kholmovski E, Morris A and Marrouche N (2019) Late Gadolinium Enhancement Magnetic Resonance Imaging Guided Treatment of Post–Atrial Fibrillation Ablation Recurrent Arrhythmia, Circulation: Arrhythmia and Electrophysiology, 12:8, Online publication date: 1-Aug-2019. June 2018Vol 11, Issue 6 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/CIRCEP.118.006480PMID: 29858384 Originally publishedJune 1, 2018 Keywordscatheter ablationcoronary sinusatrial fibrillationEditorialstachycardiaPDF download Advertisement SubjectsArrhythmiasCatheter Ablation and Implantable Cardioverter-DefibrillatorElectrophysiology